Rev: 01/09, 03/09
SATILLA COMMUNITY SERVICES
OUTCOME MANAGEMENT PLAN FOR FY 2009
The Outcome Management Plan is created within the framework of the Performance
Improvement Program, Policy 9.01. It is intended to increase the effectiveness, efficiency and
service quality of Satilla Community Services’ programs for the benefit of the people served.
The Plan outlines how information is collected and used to improve planning, operations and
1. Evaluate the effectiveness (outcomes) of programs and services in relation to their stated
purpose and impact on the lives of the people that are served.
2. Evaluate and demonstrate efficiency in the provision of services.
3. Provide management and the Satilla Community Services with objective data to assess
program performance in relation to established criteria and measures of acceptability.
4. Identify changes in the needs, preferences, and expectations of the consumer population,
and provide direction for program development.
5. Promote consumer satisfaction.
Annual Strategic Planning. The Annual Strategic Plan is created within the framework of the
Performance Improvement Program, Policy 9.01. The Annual Strategic Plan is shaped by
pooling information from a variety of sources, including input from persons served, to provide a
comprehensive and integrated basis for strategic planning which takes place in the Leadership
Team, the Satilla Community Services Board, and the Regional Board. This process shapes
the Outcomes Management Plan in accord with National, Statewide and Regional priorities and
Performance Improvement Department and Committee. The Performance Improvement
Department and Committee are created within the framework of the Performance Improvement
Program, Policy 9.01 and Management Structure, Policy 2.01. Information is collected and
collated by the Performance Improvement Department under the oversight of the Performance
Improvement Committee (meets monthly). The remit of this committee includes:
a) To identify appropriate objectives for specific programs, and for the agency as a whole,
which are set into the Outcomes Management Plan.
b) To identify appropriate specific measures for these objectives, and systems for collecting
the required information.
c) To recommend the Outcomes Management Plan to the Leadership Team.
d) To collect and review performance information on a quarterly basis.
e) To conduct and analyze needs assessments.
f) Identify and monitor available resources (in part through Utilization Management
Rev: 01/09, 03/09
Annual Management Summary. The Annual Management Summary (Annual Organizational
Report) is created within the framework of the Performance Improvement Program, Policy 9.01.
Performance Improvement Department submits an Annual Management Summary after the end
of each Fiscal Year to the Performance Improvement Committee, the Leadership Team, and the
Satilla Board. The Annual Management Summary will be based on a Balanced Score Card
approach, combining data on program effectiveness, efficiency, and cost with information on
consumer satisfaction. The Satilla Balanced Score Card was launched in FY 2004 and
monitors quarterly the performance of programs in meeting agreed targets. The Annual
Management Summary will include:
a) Reports on the extent to which the objectives set out in the annual strategic plan
b) Presents the results of the performance measures identified for each program.
c) Demonstrates the use of performance measures to improve the quality of services
and the efficiency and effectiveness of the agency.
d) Forms the basis for a review and updating of the Annual Strategic Plan.
e) Is distributed to program managers, leadership team, Board members, and to other
entities or individuals at the discretion of the Executive Director and/or the Board.
Executive Summary. Executive summaries will be made available on request to constituents
INFORMATION GATHERED AND OBJECTIVES FOR FY2009:
1. Days of Active Client Enrollment (DACE) from Georgia Regional Hospital-Savannah.
2. Improvement: Improvement in presenting problems in treatment should be
demonstrated by a mean program score of at least 85% in consumer’s response to Q #3
of the MHCA Customer Survey conducted by polling at least 15% of consumer’s served
annually. In addition, matched pairs of CAFAS and LOCUS will be measured bi-
a. Beginning FY09, the SIS assessment will be monitored as an effectiveness
measure for Community Support Services.
3. Community Integration Activities: (not reported on Balanced Scorecard)
a. Compliance with the requirement that at least 60% of contacts with consumers
be in the community for Rehabilitation Option Services.
b. A minimum of 6 hours per month of interventions promoting community
integration for all DD consumers receiving Day Services.
1. Consumer Service Time/Productivity:
a) 100 consumer service hours per month for full-time direct care Behavioral Health
providers; part-time pro rata. Contract clinicians should meet contract requirements.
b) Day service providers should achieve 100% of their maximum possible consumer-staff
ratio as outlined in the Medicaid Program Standards.
2. Cost per Consumer (not reported on the Balanced Scorecard): The intent of the Cost per
Consumer data is to have comparable data between like programs to determine efficiency of
Rev: 01/09, 03/09
3. Annual Financial Audit: The agency is required to comply with an annual financial audit.
Accessibility to Services
1. Service Response Time: The Service Response Time is utilized to ensure that consumers
are seen in clinic within five days of their initial phone contact. The target is that 90% of all
consumers will be seen face-to-face by a clinician within five days of the initial phone contact
with the Scheduling Unit, or GCAL, for a routine appointment.
2. Physician Wait Time: Physician Wait Time it utilized to ensure that consumers are seen by
a physician within an acceptable amount of time from the scheduled appointment.
3. Access Data via Satisfaction Surveys: The Intake Service Quality Survey, CARF’s mid-
treatment uSPEQ Consumer Satisfaction survey, and the Discharge Satisfaction Survey
assess for satisfaction, as well as barriers, to accessing services.
Service Quality Measures
1. uSPEQ Customer Survey: Consumer satisfaction should be demonstrated by a mean score
of at least 85% conducted by polling at least 15% of consumer’s served annually, utilizing
CARF’s uSPEQ Customer Survey Form.
2. Post Discharge Survey: Post discharge measures and consumer satisfaction in treatment
should be demonstrated by a mean program score of at least 85% by seeking a telephone
interview with at least 10% of consumer’s who are no longer receiving services with Satilla.
4. Employee Turnover and Satisfaction: Report staff turnover for all program sites and
collect employee satisfaction questionnaires from at least 85% of all employees attending
annual update training. All departing employees (excluding terminations) are invited to
complete an exit questionnaire.
5. Internal Audits: The UM Coordinator, in conjunction with the program managers, conducts
a quarterly audit for each program with the sample target size of minimum 2.5% (10%
annually) of the consumers served, which consists of documentation, service delivery, and
6. External Audits: The agency is required to comply with all external audit processes
including, but not limited to, APS, ORS, Medicaid, and Medicare.
Outcomes per Provider Contract
1. Recovery/Improved Level of Functioning: Of the adults served by Satilla for whom the
LOCUS indicates the need for at least a LEVEL-3 “High Intensity Community Based Service”
level of care upon intake, at least fifty percent (50%) shall show improvement in functioning,
as indicated by a reduction of at least one LOCUS level of care recorded in the Multipurpose
Information Consumer Profile (MICP).
2. Employment: At least 20 percent (20%) of adults served during the reporting period who are
unemployed and available for work will become employed as reported on the MICP.
3. Increased Stability in Housing: At least twenty percent (20%) of adults served during the
reporting period who report they are homeless, living in a homeless shelter, or who are at
risk of homelessness will report a stable living environment as reported on the MICP.
4. Engaging the Homeless: At least seventy-five percent (75%) of eligible consumers who
are reported to be “homeless” or “at risk of homelessness’ at intake will initiate services
within seven days of the initial contact (date of registration or assessment) and will show
evidence of treatment engagement within 30 days of initial contact as evidenced by the
MICP and encounter data reports.
Rev: 01/09, 03/09
5. Decreased Criminal Justice Involvement: At least eight-five percent (85%) of adults
served in the reporting period will have no arrests in the past 30 days at reauthorization or
6. Reduced Utilization of Psychiatric Inpatient Beds: Less than ten percent (10%) of adults
discharged from a state hospital who are assigned to the provider for services and supports
will be readmitted to a state hospital within the 30 days following discharge.
7. Hospital Utilization: Satilla will work with the Regional Provider Network to achieve the
Department’s goal of a 10% reduction in state hospital admissions and readmissions.
8. Consumer Perception of Care: Consumers reporting perception of positive change on the
Annual Consumer Survey will increase by one percentage point (1%).
Outcomes per Crisis Stabilization Program Contract
1. Episodes of Seclusion/Restraint: The target goal is to have zero episodes of
seclusion and restraint. When such an incident occurs, a form critical incident is completed,
with a full administrative review.
2. Transfers to a Higher Level of Care: If a consumer is unable to stabilize in the Crisis
Stabilization Program with 5-7 days then they will be referred to a higher level of care for
stabilization. Target goal is no more than three per quarter.
3. Length of Stay: Average length of stay for a consumer in the Crisis Stabilization Program
is 5-7 days. This excludes consumers placed on Transitional Status.
4. Re-Admits: The target goal is to have zero re-admits to the Crisis Stabilization Program
within a 30-day period.
5. Use of PRN Medications and Effectiveness: The therapeutic need for PRN medication is
discussed during staffing with the physician on a daily basis and documented in the
consumer’s records accordingly.
6. Days to Physician Assessment: The consumer will be seen by the physician within 24-
hours from admission.
7. Follow-up after Discharge: CSP staff will follow-up with consumers within five days after
Episodes of Seclusion/Restraint and Use of PRN medications with Effectiveness will be
reviewed daily during treatment team meetings with, but not limited to, the Program Director,
Staff Physician and Nurse Manager. All measures will be reviewed on a weekly basis with the
Program Director, Staff Physician and Nurse Manager and on a monthly basis with the Program
Manager, Staff Physician, Nurse Manager, Performance Improvement Coordinator, and Clinical
Director to review for trends and to implement any corrective actions, as indicated. All CSP
outcomes data will be captured on the CSP Outcomes Data form and the agency Balanced